Village health team member Janet Abieto takes delivery of a bicycle and bed-net in Katine, north-eastern Uganda. Photograph: Richard M Kavuma

Simon Eriechu understands very well the importance of his role in reducing disease in his community in north-eastern Uganda. After taking extensive training provided by government and other development partners, he has become an experienced hand in issues ranging from family planning and HIV/Aids counseling to immunisation and monitoring of minor ailments and promoting health centre services. There's just one problem: he is not working at the moment as he is on strike.

For the past two years Eriechu and fellow village health team (VHT) members have been visiting Katine residents door-to-door every fortnight to check their health and to see if they have basic essentials such as pit latrines, a bathroom, a rubbish pit, a rack for drying plates, and a clean compound. At first, when they had finished initial training, the government had supplied them with health kits containing painkillers and the anti-malarial drug, fansidar, so they could treat patients immediately – or in more serious cases refer patients to health centres.

But then drug supplies dried up, making their work difficult. Even the African Medical and Research Foundation (Amref), the development agency working in partnership with the Guardian to support the Katine community development project, has not been able to provide sufficient drugs. Despite problems, team members continued to go the extra mile. "Where we would not find any of the basics, we'd start up something for a homestead," says Eriechu.

This could mean identifying a site for a family head to dig a pit latrine and then give the homestead two weeks or so to complete it. If anyone failed to finish the task, the VHTs might then threaten to report them to the sub-county authorities for serious action which could even lead to arrests. Slowly but surely, the VHTs began to see an improvement in family hygiene and sanitation – vital ingredients in successful, long-term development.

Happier times for health teams

Charles Otuba, from Ajobi village, recalled how village health teams were key in helping him improve hygiene in his homestead. "As you can now see, I have a pit latrine, a rack for plates and a shed for my goats," he said with a smile.

Sadly, such happy endings have become rare. "Things have changed. We used to enjoy our work, [but] not anymore," said Eriechu. He has stopped actively mobilising his community to improve its health. He seemed to lack motivation - and this could clearly be seen on his face.

"We are still on strike," said Eriechu with a rather disappointed tone. "There are a few still interested," he hastens to add, "but not me."

He is not alone. Eriechu is one of the 272 VHTs who have been working with Amref in 66 villages in Katine's sub-county but chose to lay down their tools over training allowances.

Since the strike began this March, Amref has not been able to resolve a standoff with the VHTs and there is no sign of an imminent solution.

The decision to scrap financial allowances needed consultation between Amref and the VHTs but this did not happen, a fact that angers team membersincluding sub-county leadership, rendering efforts to convince VHTs return to work futile. "It is true we are volunteers but we need some money to enable us to repair bicycles that we use to move in the villages," said Eriechu.

Now, with Amref relying on VHTs for most of its programmes, such as family planning, immunisation and data collection on maternal health, the non-government agency is heading for a serious challenge in improving access to health services during the remaining period of the project.

According to Samuel Echolu, VHT coordinator in Katine, the strike has had far-reaching effects that are now spilling over into government programmes. He fears it might further undermine existing improvements in hygiene and sanitation and access to health services. "When you move to most of the homes that were doing well, things are beginning to change for the worst," he said.

He says the VHTs have also refused to implement a hand-washing campaign, a government programme being promoted in villages to reduce disease and infections resulting from poor personal hygiene. The scheme involves making community members aware of the need to have T-taps in their pit latrines and soap for washing hands after each latrine visit.

"They have even refused to implement a government programme aimed at eradicating neglected diseases like elephantiasis and hydro cells," said Echolu. "We gave the VHTs drugs and books in which they would record information regarding the progress of the programme but they have refused to return the books. I have informed the district about the problem but there is no action yet."

Staff shortages take their toll

Echolu says that unless Amref or the government finds a way out of the crisis, the VHTs will not continue to work voluntarily for their communities while having to fund themselves from their own family budgets. He fears the strike may hurt a sector already affected by staff shortages. The doctor-patient ratio of less than 1:24,000 in Uganda is a real concern, according to a 2008 World Health Organisation report. The situation for nurses is quite similar.

Although the government is striving to reduce this by training more nurses and doctors and by encouraging private institutions to invest in the health sector, the exodus of trained health practitioners taking better-paid jobs in Europe and other African countries means the doctor:patient ratio could get worse. Two hundred new doctors graduate in Uganda every year, according to the ministry of health, but a third soon go overseas.

The situation is worse in rural areas such as Katine. Most health practitioners prefer to work in urban and central regions which offer better facilities. VHTs could fill this vacuum but current propects seem slim.

There have been calls by community groups for the government to begin paying VHTs but the government says it has no funds. "We are still working on performance-related incentives. We are studying other models like in Madagascar, where communities do contribute financially. But we are also looking to donors and the finance ministry for support," said Paul Kagwa, assistant commissioner in charge of health promotion at Uganda's ministry of health, who was recently quoted in the Ugandan daily newspaper, New Vision.

Research by Dr Flavia Mpanga-Kaggwa, a health specialist at Unicef, reveals that the key motivating factors for volunteers joining village health teams were financial reward and recognition - a sort of "status" within a community afforded VHTs because of the role they play. This might mean "recognition" by a speaker at public gatherings or being allowed to get water without lining up. VHTs have suffered lack of recognition partly because supplies of government-funded medicines they were meant to distribute in their communities dried up.

Amref recently hired a UK-based consultant for an end of year 3 review and the issue of VHTs is understood to have been one of the areas of focus. But the issue remains unresolved.

New Katine project manager Frederick Kabikira said: "We are planning to meet with the acting Soroti district health inspector to see how he can dialogue with the VHTs so as to chart a way forward."